TRIAGE

INTRODUCTION

The word triage comes from the French word trier, which means to sort or select. Its historic
roots for medical purposes go back to the days of Napoleon when triaging large groups of
wounded soldiers was necessary. Over the centuries, triage systems have evolved into a well-
defined priority process, sometimes requiring specific training depending on the setting or
organization that uses the system.

DIFINITION

Triage refers to the evaluation and categorization of the sick or wounded when there are
insufficient resources for medical care of everyone at once. Historically, triage is believed to
have arisen from systems developed for categorization and transport of wounded soldiers on the
battlefield.

USES

Triage is used in a number of situations in modern medicine, including:

 In mass casualty situations, triage is used to decide who is most urgently in need of
transportation to a hospital for care (generally, those who have a chance of survival but
who would die without immediate treatment) and whose injuries are less severe and must
wait for medical care.

 Triage is also commonly used in crowded emergency rooms and walk-in clinics to
determine which patients should be seen and treated immediately.

 Triage may be used to prioritize the use of space or equipment, such as operating rooms,
in a crowded medical facility.

In a walk-in clinic or emergency department, an interview with a triage nurse is a common first
step to receiving care. He or she generally takes a brief medical history of the complaint and
measures vital signs (heart rate, respiratory rate, temperature, and blood pressure) in order to
identify seriously ill persons who must receive immediate care.

In a hospital, triage might prevent an operation for an elective facelift from being performed if
there are numerous emergent cases requiring use of operating facilities and surgical nursing staff.

TRIAGE CATEGORIES

In a disaster or mass casualty situation, different systems for triage have been developed. One
system is known as START (Simple Triage and Rapid Treatment). In START, victims are
grouped into four categories, depending on the urgency of their need for evacuation. If
necessary, START can be implemented by persons without a high level of training. The
categories in START are:
  the deceased, who are beyond help

 the injured who could be helped by immediate transportation

 the injured with less severe injuries whose transport can be delayed

 those with minor injuries not requiring urgent care

Another system that has been used in mass casualty situations is an example of advanced triage
implemented by nurses or other skilled personnel. This advanced triage system involves a color-
coding scheme using red, yellow, green, white, and black tags:

 Red tags - (immediate) are used to label those who cannot survive without immediate
treatment but who have a chance of survival.

 Yellow tags - (observation) for those who require observation (and possible later re-
triage). Their condition is stable for the moment and, they are not in immediate danger of
death. These victims will still need hospital care and would be treated immediately under
normal circumstances.

 Green tags - (wait) are reserved for the "walking wounded" who will need medical care
at some point, after more critical injuries have been treated.

 White tags - (dismiss) are given to those with minor injuries for whom a doctor's care is
not required.

 Black tags - (expectant) are used for the deceased and for those whose injuries are so
extensive that they will not be able to survive given the care that is available.

TRIAGING PROCESS
Triaging should not take much time. In the child who does not have emergency signs, it takes on
average twenty seconds.
 Assess several signs at the same time. A child who is smiling or crying does not have
severe respiratory distress, shock or coma.
 Look at the child and observe the chest for breathing and priority signs such as severe
malnutrition.
 Listen for abnormal sounds such as stridor or grunting.

Priorities of care and triage categories:-

Standardized triage categories are usually developed within each emergency department.
Most common triage systems consist of five levels of acuity.
 Triage Level- 1- Resuscitation:-
1. Conditions requiring immediate nursing and physician assessment. Any delay in treatment
is potentially life or limb threading.
2 .Includes conditions such as:
 Airway compromise.
 Cardiac arrest.
 Severe shock.
 Cervical spine injury.
 Multisystem trauma.
 Altered level of consciousness.
 Eclampsia.
The colour code for this category of triage is Red.
Triage Level – II - Emergent:-
1. Condition requiring nursing assessment and physician assessment within 15 minutes of
arrival.
2. Condition includes
 Head injuries.
 Severe trauma.
 Lethargy or agitation.
 Conscious overdose.
 Severe allergic reaction.
 Chemical exposure to the eyes.
 Chest pain.
 Back pain.
 G.I bleeds with unstable vital signs.
 Stroke with deficit.
 Severe asthma.
 Abdominal pain in patients older than age 50.
 Vomiting and diarrhea with dehydration.
 Fever in infants younger than 3 months.
 acute psychotic episode.
 Severe headache.
 Any pain greater than 7 on a scale of 10.
 Any sexual assult.
The Colour code in this level is Yellow.
Triage level III- Urgent:-
1. Condition requiring nursing and physician assessment within thirty minutes of arrival.
2. Condition includes.
 Alert head injury with vomiting.
 Mild to moderate asthma.
 Moderate trauma.
 Abuse or neglect.
 G.I bleeds with stable vital signs.
 History of seizure, alert on arrival.
The Colour code in this level is Yellow.
Triage level IV- Less urgent
1. Conditions requiring nursing and physician, assessment within one hour.
2. Conditions include:-
 Alert head injury without vomiting.
 Minor trauma.
 Vomiting and diarrhea in patient older than age 2 without evidence of dehydration.
 Earache.
 Minor allergic reaction.
 Corneal foreign body.
 Chronic back pain.
The Colour code in this level is Green.
Triage level – V – Non-urgent:-
1. Conditions requiring nursing and physician assessment within 2 hours.
Conditions include:
 Minor trauma, not acute.
 Sore throat.
 Minor symptoms.
 Chronic abdominal pain.
The Colour code in this level is Green.

Triage level –VI-Expectant:-

1.Injuries are extensive and chances of survival are unlikely even with definitive care.
persons in this group should be separated from other casualties, but not abandoned. comfort
measures should be provided when possible.
2.conditions include:-
 Unresponsive patients with penetrating head wounds.
 High spinal cord injuries.
 Wounds involving multiple anatomical sites and organs.
 2nd/3rd degree burn excess of 60% of body surface area.
 Seizure or vomiting within 24 hours after radiation exposure.
 Profound shock with multiple injuries.
 Agonal respirations, no pulse, no B.P, pupils fixed and dilated.
The Colour code in this level is Black.
 BIBLIOGRAPHY:-

1.LeMone Priscilla , Burke Karen , Medical – Surgical Nursing , Critical Thinking In Client

Care , Published by Dorling Kindersely(India) Pvt. Ltd. ,4th Edition , Pp(133-134)

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Indian 8th Edition Pp(813-814).

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Website link:-

5. http://en.wilipedia.org./wili/triage

6. www.medicinet.com/script/main/art.asp